AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Mental Illness versus Illicit and other Substances, The Effects of
Substances & Illegal Drugs on Young People with A Mental illness: Centacare MASC's
Team Approach.
Written by Carmel Johnston and Ivan Thorne Centacare Ballarat.
Context
Two Case Studies
Strategies Utilised
Conclusion
Summary
In 1999 Centacare commenced the establishment of a new residential service for young adults aged 16 to 24, entitled Making a Significant Change (MASC). This was a new service type for Victorian psychiatric disability services, and is one of five Psychiatric Disability Support Service types purchased by the Victorian Department of Human Services. The Victorian Department Of Human Services tender brief was clear as to the program's prime function being to facilitate the transition to young adulthood, including continuation of education and training and the move to more independent living. It was aimed to achieve this through an intensive residential psychosocial rehabilitation program located in the community, in preference to frequent or extended in-patient admissions.
This was also the Victorian Government’s response to the 1997/98 Suicide Prevention Taskforce recommendations specifically targeting the needs of young adults who have a mental illness and who are at risk of developing psychiatric disabilities or self harm behaviours, substance abuse being one of these behaviours.
In establishing the service it became very clear that substance abuse was a factor in all referrals to the service. This included alcohol, marijuana, heroin, amphetamines and inhalants such as paint and glue, and any other substances readily available to the young people being referred.
The original service model, which had envisaged some substance abuse issues, was not, however, developed for 90% substance use by the young people. Due to the large amounts of substances being abused by the residents, the program staff identified the need to examine the current program to maintain the therapeutic nature of the MASC community whilst addressing the issue of high substance abuse.
The program undertook internal and external program reviews at the six month stage of development. There were six participants in the program at this time, living in outreach settings, whilst awaiting refurbishment of the permanent residential site.
This outreach gave the staff valuable information, which aided the team, including the
writers, to redevelop the assessment process, which was extended to a minimum of six weeks
involvement with the young person from the time of referral. This time period also
highlighted the need to change components of the program to address developmental needs of
young people who have mental health issues combined with serious substance use.
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In examining two of the most difficult presentations to the program – one with a diagnosis of schizophrenia and the other of manic depression. The writers found the young people very hard to engage, therefore making it extremely difficult to ascertain acknowledgment of the use of illegal substances and the effect, if any, it was having on their diagnosed mental illnesses.
(Bradley & Toohey, 1999 unpublished) describe a dual diagnosis client as "an individual who has a Co-existing mental illness and substance abuse disorder without a determination of which disorder is causative or primary, or an individual with a mental illness and Co-existing problematic substance use condition which seriously precipitates or exacerbates positive and negative symptoms of their mental illness."
Because of the lack of, or only rare acknowledgment of the fact that they were involved in illegal substance abuse, astute observation was the only means by which the required facts could be ascertained to enable the workers to put into place measures to assist these young people to become involved in the program and to help them to improve their quality of life.
Many other negative aspects of the young people's demeanour were also apparent, which were considered to be impeding their individual growth. There was an attitude that to self medicate on illegal substances was far more beneficial to their social life because they were more accepted by ‘normal ‘ society than they would be if they took their prescribed medication. However, for the workers, this was not accepted as the only reason that drug usage was so prevalent in the young people’s lifestyles. "For some people, the substance use began with an attempt by the person to self medicate depressed or anxious feelings." (Source unknown)
Both young people had experienced major traumas prior to entering the program and this had affected their self-esteem, resulting in poor social skills and extreme anti-social behaviour. The majority of the time they failed to comply with any authoritative figures, this included non compliance with medication and failure to keep appointments, including attending counselling for drug and alcohol abuse, resulting in police and court involvement, eviction from properties, breakdown of family relationships and friendships and a change of lifestyle which was knowingly unacceptable to them but over which they had no control. It was apparent that drug taking took priority to the detriment of everything else concerning their lives and environment.
Lack of motivation is also a contributing factor for these young people to rectify their social status. Although self-esteem issues are usually behind this behaviour it is important that workers establish why, and exactly what the reason is. This can be achieved in spending quality time with the young person in a casual comfortable setting, eliciting facts that may lead to reasons for their non-motivational mood. It has been found that pens and paper discourage the young people from discussing their problems.
This process can be used in many similar situations to establish the cause of moods such as sadness, lethargy, feelings of worthlessness, anxiousness, suicidal and homicidal ideations, and behaviours such as sleep disturbances and appetite disruptions. A continuation of these mentioned moods may lead to a persistence of, and unrealism and exaggeration of their circumstances.
Even though both young people display seemingly carefree attitudes they can become highly emotional when they have no funds to purchase tobacco, alcoholic products and illicit substances but tend to manage emotionally and physically if there is no money available for rent, food, transport, entertainment or recreation.
The workers early identification of changes of patterns in the young people's lives is crucial in preventing a crisis occurring, or intervening prior to a potential crisis further developing for them. Intervention models, which are then put into place, must be followed up and maintained.
High-risk behaviours were an obvious factor in the lives of these two young people and this made it very difficult for staff to manage their day to day activities. Except for focusing on one to one contact over extended periods of time so as keep track of their location, they will generally disappear, and when they reappear it is not unusual for them to have partaken of some form of drug or alcohol abuse, anti-social behaviour or self harm behaviour.
Cannabis is the most common illegal substance used but, generally, when the desire occurs to partake of substances, anything that they can acquire is utilised. One young person we are focusing on tends to have a preference for chroming, usually using spray paint cans but also soda bulbs on occasions. His preference for these means of illicit substances stems from the fact that when funds are unavailable to him to purchase more common drugs he can obtain these in illegal ways and thus still satisfy his needs.
These situations pose a threat to the young person’s sense of control often resulting
in sexual behaviour increasing the risk of sexually transmitted diseases,
illegal activities, poor nutrition affecting both physical and mental health, poor daily
living skills, lack of family support or reconciliation, none or very few recreational
activities and restricted education and employment chances.
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To allow the young people every opportunity to proceed in a positive manner, motivational interviewing is commonly utilised. This allows the young people an opening for supportive change in their lives from within, rather than from external sources. As workers we counsel in a supportive role rather than an authoritarian role and help them recognise their past, present and potential problems. To give the young person a choice rather than a directive results in a more positive outcome. Rather than dwelling on these problems it allows them to move on because of their own suggestions and problem solving, and gives them the confidence to realise that they do have the ability to make and develop their own decisions, therefore creating an increase in their self esteem. Forgetting the past and concentrating on the future is a responsibility given to the young person through support and positive reinforcement. Using this method of problem solving reduces reluctance that can be present when other parties make decisions for them.
To break a formed habit can be a very difficult exercise and substitutions for the formed habit are an integral part of breaking that habit. Keeping the young people occupied either individually or in group settings is part of the process of altering that regime with assisted daily chores, tasks, program activities including cooking, gardening, building, woodworking, arts and crafts and recreational and leisure activities.
One of the young people to whom we are referring was invited to perform a self monitoring process of his daily activities, which resulted in him acknowledging his behaviour that was detrimental to his anger levels and social skills, which impeded his ability to operate appropriately within both a therapeutic and general community setting.
The MASC program makes a concentrated effort to involve families and carers in the rehabilitation of the young people. They are invited to participate in any decision making involving the young person, with the young person’s permission, plus facilities have been made available for them to stay on site, either with their family member or in bedroom set aside for this purpose in the administration building. Family members are also encouraged to participate in meals and activities within the program.
The success of the MASC program is probably best reflected in the number of hospital
admissions that have been made in the time that the program has been operational. Eleven
young people have passed through, or are currently in the program, and only three
admissions of less than five days have been made.
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The writers have found in the MASC program that:
- Young people with mental health and substance abuse issues? Benefit from preparation for rehabilitation. In the two cases that were studied there was serious mental illness in the order of Schizophrenia and Manic-Depressive Psychosis, with the added effects of the large amounts of substances being consumed. The writers believe extensive support needs to be given to regain social living skills and thus social acceptance. . The young people need to have accommodation away from the therapeutic community site in the first instance, with the goal to move onto the therapeutic community site when they have gained some social and interpersonal skills which assists them to live with others. This process should be identified in their Individual Program Plan (IPP).
- Collaborative links need to be made to ensure quality and appropriate support is given. These should include local area mental health services, Dual Diagnosis mental health and drug and alcohol support workers as well as Psychiatric Disability Support Residential Rehabilitation Key Support Workers. When the young person receives consistent quality one on one support drug use and consequently aggression decreases, allowing goals of support for the young person to be achieved.
- Firm boundaries need to be made from the onset of support and there must be commitment from the team to enforce these boundaries. Such boundaries should include withdrawal of support when the young person is intoxicated, and/or aggressive and abusive towards others and property. Consequences such as no contact for twenty-four hours with program activities should be enforced a contract should be developed outlining such plans. Positive behaviours should be recognised as well as the negative.
- When staff have demonstrated consistency in their approach to the young people in the cases studied it has been shown that there has been a positive lifestyle change. One other factor noted was the impact of consistency of the support people. If there was a change, for example individual support staff members on leave, the substance intake increased. Where possible there should be two primary support people with the whole team being involved in the support. When appointments are made workers should be punctual and consistent in attending at appointed times; they can then expect the young person to do the same. Support should be given in an environment where the young person is comfortable.
- Family and significant others should be included in the support plan of the young
person; an identified friend may be the only support for the young person when they are
going though the challenge of stepping outside of their comfort zone.
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Finally, when looking at the two cases studied, a pattern arose showing that when the support people were frank and to the point, utilising an open honest approach to the young people their motivation and self esteem increased and their attitude, physical behaviour and aggression decreased.
The individual support worker needs to ensure that the team follows the same approach as the individual worker. When this was done it consistently showed a marked enhancement in the person attempting an activity or something they were reluctant to attempt because of previous experiences.
With the approaches detailed in this paper, goals identified in both cases have been achieved. One young person continues to be involved in the program and engages with other participants and the team.
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